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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602277
Report Date: 01/17/2023
Date Signed: 01/17/2023 12:06:29 PM

Document Has Been Signed on 01/17/2023 12:06 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BENCY'S RANCHFACILITY NUMBER:
374602277
ADMINISTRATOR:MARILYN B JIMENEZFACILITY TYPE:
735
ADDRESS:731 W 16TH AVETELEPHONE:
(760) 743-8179
CITY:ESCONDIDOSTATE: CAZIP CODE:
92025
CAPACITY: 6CENSUS: 4DATE:
01/17/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Melissa Sumibcay, AdministratorTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit for the purpose of conducting a case management visit concerning a prior resident death. LPA met with Administrator, Melissa Sumibcay who was informed of the purpose of the visit.

At the time of the visit there were (4) staff and (1) resident present. LPA observed resident #1 (R1) was in their bedroom watching the television. Staff informed LPA other (3) residents were at their day program. LPA conducted a walk through of the facility and did not observe any health and safety issues. LPA observed the facility utilities were running with no issue, food supply is sufficient for (4) residents, and medications are at least a 30-day supply.

LPA conducted interviews with staff present, collected documentation and contact information for staff. LPA advised the administrator of documents that would need to be sent to LPA as soon as possible. The administrator was advised that at this time the department is still looking into the incident and the matter is an ongoing investigation.

Am exit interview was conducted were this report was reviewed and provided to Administrator, Melissa Sumibcay.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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